The present invention relates generally to peritoneal dialysis and renal replacement therapies, such as hemofiltration and hemodiafilitration. More specifically, the present invention relates to manufacturing and storing bicarbonate-based solutions for peritoneal dialysis and hemofiltration.
To overcome the disadvantages often associated with classical hemodialysis, other techniques were developed, such as peritoneal dialysis and hemofiltration. Peritoneal dialysis utilizes the patient""s own peritoneum as a semipermeable membrane. The peritoneum is the membranous lining of the body cavity that, due to the large number of blood vessels and capillaries, is capable of acting as a natural semipermeable membrane.
In peritoneal dialysis, a sterile dialysis solution is introduced into the peritoneal cavity utilizing a catheter. After a sufficient period of time, an exchange of solutes between the dialysate and the blood is achieved. Fluid removal is achieved by providing a suitable osmotic gradient from the blood to the dialysate to permit water outflow from the blood. This allows a proper acid-base, electrolyte and fluid balance to be returned to the blood. The dialysis solution is simply drained from the body cavity through the catheter.
Hemofiltration is a convection-based blood cleansing technique. Blood access can be venovenous or arteriovenous. As blood flows through the hemofilter, a transmembrane pressure gradient between the blood compartment and the ultrafiltrate compartment causes plasma water to be filtered across the highly permeable membrane. As the water crosses the membrane, it convects small and large molecules across the membrane and thus cleanses the blood. An excessive amount of plasma water is eliminated by filtration. Therefore, in order to keep the body water balanced, fluid must be substituted continuously by a balanced electrolyte solution (replacement or substitution fluid) infused intravenously. This substitution fluid can be infused either into the arterial blood line leading to the hemofilter (predilution) or into the venous blood line leaving the hemofilter.
In addition to the removal of metabolic products, one of the most important problems of every kidney replacement therapy, such as hemodialysis, hemofiltration and peritoneal dialysis, lies in the correction of metabolic acidosis. For this reason, the dialysis solutions used in each of these processes contain a buffer.
Three common buffers often used in dialysis solutions are bicarbonate, lactate, and acetate. While initially bicarbonate was the primary buffer used in dialysis solutions, over time lactate and acetate were used as substitutes for bicarbonate. This was due to the difficulty in preparation and storage of bicarbonate-buffered dialysis solutions. Lactate and acetate buffers were found to provide greater stability in use over the previous bicarbonate-buffered solutions. See U.S. Pat. No. 5,211,643.
However, since bicarbonate ions provide advantages over acetate or lactate ions, bicarbonate is again surfacing as the primary buffer used in dialysis solutions. Tests have been conducted that indicate patients exhibit a better tolerance for bicarbonate dialysis solutions. In patients with a multiple organ failure, bicarbonate-buffered solutions are preferred because of the lack of metabolic interference. Further, certain treatments require sterile dialysis solutions containing bicarbonate, calcium and magnesium.
For example, one may have to dialyze a uremic patient who has developed hypotension and lactate acidosis. In such a patient, the lactate or acetate in conventional dialysates may not be metabolized to bicarbonate because of tissue hypoxia, and acidosis may be further worsened because bicarbonate is removed during dialysis. Using bicarbonate-containing dialysates in such a patient will add bicarbonate to the blood and also remove lactate. For these reasons, some researchers have recommended bicarbonate-buffered dialysis as adjunctive treatment for severe lactate acidosis. T. S. Ing. et al, Bicarbonate-buffered peritoneal dialysis, The International Journal of Artificial Organs, Volume 8, No. 3, p. 121-124 (1985).
Another potential application of bicarbonate-buffered solutions may be for patients who experience abdominal pain or discomfort when conventional acetate- or lactate-buffered dialysates are infused. The abdominal pain may be related to the unphysiologically high acidity of acetate- and lactate-buffered dialysates. Conceivably, bicarbonate-buffered dialysate, with its more physiologic pH, might decrease the incidence of such symptoms. Id.
The use of medical bicarbonate solutions for injection or for dialysis treatment is known. However, due to the difficulty in preparation and storage of these solutions, a vast array of literature is dedicated to attempts to remedy the stability problem of bicarbonate solutions. Three main problems need to be addressed when manufacturing and storing medical bicarbonate solutions.
First, in solution, bicarbonate is in equilibrium with CO2 gas, which easily escapes from the solution. As a result, carbonate, a potential irritant, may form, and the pH of the solution is thereby increased. To avoid these phenomena from occurring, the bicarbonate can be stored in a powder form until just before use as described in U.S. Pat. No. 4,489,535 and Jonsson et al, European Patent Application 0 278 100 for machine-controlled dialysis.
Alternatively, an impermeable gas barrier can be used to protect the solution. Or, for hemodialysis, the CO2 content of the solution can be controlled as described in Murphy et al, Use of An Artificial Kidney, J Lab. Clin. Med., Volume 40, pp. 436-444 (1952). U.S. Pat. No. 4,584,176 and European Patent No. 0 209 607 describe controlling the CO2 content of a bicarbonate-based solution. Moreover, the addition of buffers, such as glycylglycine, has been proposed to further stabilize the bicarbonate solution. See U.S. Pat. No. 4,959,175.
Still further, another approach focuses on generating carbon dioxide within a container to stabilize bicarbonate solutions. See U.S. Pat. No. 5,383,324. In the ""324 patent, a device can be used to generate and maintain carbon dioxide pressure within a container. The device can either be positioned within a container that houses the bicarbonate solution or within an overpouch that surrounds the container filled with the bicarbonate solution. The device can be used before, during or after steam sterilization.
Second, bicarbonate solutions for injection and for dialysis generally contain calcium and/or magnesium ions. In the presence of bicarbonate, these ions form calcium carbonate and magnesium carbonate, respectively, which at increased pHs typically precipitate from the solution. To initially remedy this problem, bicarbonate solutions are often made from concentrates, ranging from slightly concentrated, two-fold or less, to much more concentrated solutions. Bicarbonate on the one hand and calcium and/or magnesium on the other hand are included in separate concentrates. These concentrates are then mixed to obtain a ready-to-use solution. Alternatively, the concentrates are mixed and diluted or diluted and mixed.
In order to avoid the precipitation of carbonate salts, some have suggested the bicarbonate concentrate should be acidified when manufactured. See U.S. Pat. No. 5,211,643. Specifically, the ""643 patent proposes adjusting the pH value of the bicarbonate concentrate to less than 7.6 by addition of a physiologically tolerable acid.
Alternatively, others have proposed to leave the pH of the bicarbonate concentrate unadjusted. See U.S. Pat. No. 4,489,535. Left unadjusted, the pH of the bicarbonate concentrate is about 8.0-8.4. The Merck Index, 12th Ed., Merck Research Laboratories, Whitehouse Station, N.J., p. 1472 (1996); Boen S T, A clinical study of factors governing its effectiveness, Peritoneal Dialysis, p. 76, Van Gorcum and Comp, Assen, The Netherlands (1959); Odel H M et al., Peritoneal lavage as an effective means of extrarenal excretion. A clinical appraisal, American Journal of Medicine, 9, 63-77 (1950). The unadjusted bicarbonate concentrate is then mixed with an acid or acidified concentrate, either before or after dilution if dilution is needed. Acidification has been achieved with organic acids (acetic acid, lactic acid), inorganic acids (hydrochloric acid) or with carbon dioxide. Ing. et al, Bicarbonate-buffered peritoneal dialysis, Volume 8, No. 3, p. 121-124 (1985).
The problem with both of these approaches is that the bicarbonate based solution needs a gas barrier, either as a primary container or as an overwrap. In case of accidental damage to the gas barrier, the bicarbonate concentrate will lose carbon dioxide, and the pH will increase. Upon mixing of the acid concentrate with the bicarbonate concentrate, the pH of the bicarbonate concentrate will no longer match with the pH of the acid concentrate. The mixed solution will no longer be in the physiologic range, and a calcium carbonate precipitate will form immediately upon mixing.
To avoid gas barrier damage, thick containers have been used instead of flexible containers. However, these do not collapse upon draining and therefore need to be vented for use in peritoneal dialysis or hemofiltration. This has the inherent risk of infection.
U.S. Pat. No. 5,296,242 to Zander describes the use of a stable aqueous solution in the form of two separately stored single solutions, one containing a metabolizable organic acid, the other alkali bicarbonate and alkali carbonate. The ""242 patent relates to adjusting the pH of the dextrose compartment with an organic acid; the dextrose compartment is adjusted to a pH range of 4.0 to 6.0. Not only do the inventors believe a physiological solution will not be achieved with such a high pH for the dextrose component, problems arise from the use of organic acids. For example, in patients with liver failure, the body has difficulty in metabolizing organic acids, and it is therefore preferable to have all buffer available as bicarbonate. In case of peritoneal dialysis, the presence of organic acids and dextrose in the same container will enhance the formation of glucose degradation products, which in turn may damage the peritoneal membrane.
Third, bicarbonate solutions for injection and for certain types of dialysis need to be sterile. Sterile filtration, steam sterilization, radiation or another suitable sterilization method may be used. When steam sterilization is used, many substances cannot be autoclaved together with bicarbonate. Therefore, the solution must be sterilized in at least two parts: one part containing the bicarbonate; and another part containing the incompatible substances(s), such as dextrose. In practice, two containers can be used, or alternatively, multi-compartment containers can be used. See U.S. Pat. Nos. 4,396,383 and 4,465,488.
In light of the problems associated with bicarbonate-based solutions, bicarbonate solutions for peritoneal dialysis are typically either prepared in the hospital just before use or are stored in a two-chamber container made of a steam-sterilizable gas barrier material. Of course, preparing the bicarbonate solution in the hospital is time-consuming and poses sterility problems. On the other hand, the steam-sterilizable gas barrier materials are expensive and the barrier may be accidentally lost due to damage during production and/or transportation.
Therefore, a need still exists for an improved way to manufacture and store bicarbonate-based solutions.
The present invention provides devices and methods for stabilizing bicarbonate-based peritoneal dialysis solutions. Specifically, the present invention relates to a new way to formulate a bicarbonate-based solution for peritoneal dialysis or hemofiltration. The solution of the present invention is formulated and stored in at least two partsxe2x80x94an alkaline bicarbonate concentrate and an acidic concentrate. The invention focuses on the adjustment of the chemical parameters and the pH levels of the concentrates, so that upon mixing, the two concentrates always provide a solution with an acceptable pH in the physiologic range. The invention surprisingly avoids the need for carbon dioxide addition to the bicarbonate solution as well as the use of an expensive gas barrier material, which were used previously to maintain the stability of a bicarbonate-based solution. Also, it does not require the use of organic acids or other undesired substances.
The present invention provides a two-part bicarbonate containing solution. The first part of the solution is housed in a first container. The first part includes an alkaline bicarbonate concentrate whose pH is adjusted to about 8.6 to 10.0. The second part of the solution is housed in a second container. The second part includes an acidic concentrate having a pH effective to obtain, when the first part and the second part are mixed together, a mixed solution having a pH ranging from about 6.5 to 7.6. The pH of the acidic concentrate preferably ranges from about 1.0 to 3.0. In a preferred embodiment, the first and second containers are two chambers of a multi-chamber container.
The pH of the alkaline bicarbonate is chemically adjusted upwards at the time of manufacture to more alkaline values. Initially, when prepared, the bicarbonate concentrate has a pH of 8.0-8.4. Chemically increasing the pH of the bicarbonate component upwards is indeed counter intuitive as the desired pH range for the mixed solution is 6.5 to 7.6 (close to the pH of blood) which is well below the pH of a freshly made bicarbonate solution. Further, container interactions generally increase at more extreme pH values. Nevertheless, the inventors found that adjusting of the bicarbonate component to these alkaline pH values, combined with a dextrose component at a low pH yields a stable product that does not need a gas barrier.
In one embodiment, the pH of the bicarbonate-based concentrate is chemically adjusted to about 8.6, and allowed to adjust further over time during storage. The inherent instability of the concentrate effectively increases the pH with time and storage due to carbon dioxide loss until it reaches a steady state level of about 9 to 10. The pH naturally rises during storage when the solution is housed in a gas permeable container. However, the initial adjustment allows to obtain a pH in a physiological range (6.5-7.6) after mixing.
Alternatively, the alkaline bicarbonate concentrate is adjusted by adding a physiologically acceptable base to the aqueous solution containing sodium bicarbonate having an original pH of about 8.0-8.4 to increase the pH thereof to a pH of about 9.0 to 10.0.
The inventors have found that when the bicarbonate concentrate is either formulated or naturally allowed to obtain a pH of about 9.0 to 10.0, the pH of the bicarbonate-based concentrate is in a steady state and is in equilibrium with the ambient air. With a bicarbonate concentrate starting at about pH 8.6, although there is some variation in the pH of the mixed bicarbonate solution, the inventors have discovered that with the appropriate selection of the parameters of the concentrates, particularly the pH of the dextrose concentrate, the pH of the mixed solution is always within an acceptable physiological pH range (6.5-7.6). The invention again focuses on the adjustment of the chemical parameters and the pH levels of the concentrates.
In a preferred embodiment, the present invention provides a multi-chamber container for storing a bicarbonate-based solution for peritoneal dialysis or hemofiltration. The container includes a first chamber housing an alkaline bicarbonate concentrate. The alkaline bicarbonate concentrate is adjusted to have a pH in a range of about 8.6 to 10.0. The second chamber of the multi-chamber container houses an acidic concentrate. The acidic concentrate has a pH of about 1.0-3.0, so that, when the alkaline bicarbonate concentrate is mixed with the acidic concentrate, a mixed solution having a pH in a physiologic range of about 6.5 to 7.6 is obtained. In a preferred embodiment, the acidic concentrate has a pH of about 1.3 to 2.5.
The present invention also provides a method for stabilizing bicarbonate solutions. The method includes the step of housing an alkaline bicarbonate concentrate in a first container and housing an acidic concentrate in a second container. The pH of the alkaline bicarbonate concentrate is adjusted to a range of about 8.6 to 10.0. Further, the acidic concentrate is adjusted to a pH effective to obtain, when the alkaline bicarbonate concentrate is mixed with the acidic concentrate, a mixed solution having a pH ranging from about 6.5 to 7.6. Preferably, the acidic concentrate has a pH ranging from about 1.0 to 3.0.
An advantage of the present invention is that it provides new apparatuses and methods for formulating a bicarbonate-based peritoneal dialysis solution.
Another advantage of the present invention is that it avoids the use of an expensive gas barrier material to maintain the stability of bicarbonate-based solutions. Such steam sterilizable gas barrier materials are expensive, rarely fail proof and are not required when using the present invention. The invention therefore solves the problem of maintaining the physical integrity of the gas barrier materials during manufacturing and storage. Consequently, the invention allows for the production of sterile bicarbonate-based peritoneal dialysis solutions in a manufacturing plant at very low cost and to ship a chemically stable product to the hospital or a patient""s home.
Yet another advantage of the present invention is that it ensures that the bicarbonate solution can be stored for long periods of time, while it makes a gas barrier redundant. The two-part solution is stable for more than six months.
Moreover, an advantage of the present invention is that a ready-to-use bicarbonate-based solution with a physiologic pH range can be obtained without using expensive gas barrier materials.
Additional features and advantages of the present invention are described in, and will be apparent from, the detailed description of the presently preferred embodiments as well as the drawings.